Michael P. Bergen

Physical capacity in wheelchair-dependent persons with a spinal cord injury : a critical review of the literature

Study design:Review of publications.Objective:To assess the level of physical capacity (peak oxygen uptake, peak power output, muscle strength of the upper extremity and respiratory function) in wheelchair-dependent persons with a spinal cord injury (SCI).Setting:Erasmus MC, University Medical Centre Rotterdam, The Netherlands.Methods:Pubmed (Medline) search of publications from 1980 onwards. Studies were systematically assessed. Weighted means were calculated for baseline values.Results:In tetraplegia, the weighted mean for peak oxygen uptake was 0.89 l/min for the wheelchair exercise test (WCE) and 0.87 l/min for arm-cranking or hand-cycling (ACE). The peak power output was 26 W (WCE) and 40 W (ACE). In paraplegia, the peak oxygen uptake was 2.10 l/min (WCE) and 1.51 l/min (ACE), whereas the peak power output was 74 W (ACE) and 85 W (WCE). In paraplegia, muscle strength of the upper extremity and respiratory function were comparable to that in the able-bodied population. In tetraplegia muscle strength varied greatly, and respiratory function was reduced to 55–59% of the predicted values for an age-, gender- and height-matched able-bodied population.Conclusions:Physical capacity is reduced and varies in SCI. The variation between results is caused by population and methodological differences. Standardized measurement of physical capacity is needed to further develop comparative values for clinical practice and rehabilitation research.Sponsorship:Supported by the Health Research and Development Council of The Netherlands (grant nos. 1435.0003; 1435.0025).

A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge

OBJECTIVES To assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons. DESIGN Prospective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge. SETTING Rehabilitation center in The Netherlands and the participants home. PARTICIPANTS Persons (n=40) with SCI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays. RESULTS Random coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge. CONCLUSIONS The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge.

Barriers to and facilitators of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre

OBJECTIVE To determine the most important barriers to and facilitators of the level of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre. DESIGN Qualitative study with both cross-sectional and retrospective questions. SUBJECTS Thirty-two persons with a spinal cord injury. METHODS Semi-structured interview with questions concerning the current situation (>9 months after discharge) and retrospective questions concerning the period shortly after discharge (=3 months). The interview consisted of 10 topic categories assumed to have an impact on the level of everyday physical activity and covering the main parts of the International Classification of Functioning, Disability and Health (ICF) model. RESULTS In the current situation, the most important barriers were problems with accessibility of stores and buildings, physical health problems and mental health problems. Shortly after discharge, the most important barriers were emotional distress, problems with self-care, and mental health problems. The most frequently mentioned facilitators were preparation in the rehabilitation centre with respect to daily activities and social activities and stimulation to be physically active. CONCLUSION Persons with a spinal cord injury experience important barriers to physical activity, particularly on the ICF component Body Functions and Structure.

COMPLICATIONS FOLLOWING SPINAL CORD INJURY: OCCURRENCE AND RISK FACTORS IN A LONGITUDINAL STUDY DURING AND AFTER INPATIENT REHABILITATION

OBJECTIVE To assess the occurrence and risk factors for complications following spinal cord injury during and after inpatient rehabilitation. DESIGN Multicentre longitudinal study. SUBJECTS A total of 212 persons with a spinal cord injury admitted to specialized rehabilitation centres. METHODS Assessments at the start of active rehabilitation (n=212), 3 months later (n=143), at discharge (n=191) and 1 year after discharge (n=143). RESULTS Multi-level random coefficient analyses revealed that complications were common following spinal cord injury. Most subjects reported neurogenic and musculoskeletal pain, or had spasticity at each assessment. During the year after discharge, complications remained common: urinary tract infections and pressure sores affected 49% and 36% of the population, respectively. The degree of pain decreased, whereas the degree of spasticity increased significantly during inpatient rehabilitation. Overall, increased age, increased body mass index, traumatic lesion, tetraplegia, and complete lesion all increased the risk of complications. CONCLUSION Complications are common following spinal cord injury. They need specific attention after discharge from inpatient rehabilitation and within subpopulations.

Chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy

Aim  To investigate the prevalence and co‐occurrence of chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy (SBCP) and explore associations of chronic pain and fatigue with depressive symptoms and daily functioning.

Inactive lifestyle in adults with bilateral spastic cerebral palsy

OBJECTIVE To quantify the level of everyday physical activity in adults with bilateral spastic cerebral palsy, and to study associations with personal and cerebral palsy-related characteristics. PARTICIPANTS AND METHODS Fifty-six adults with bilateral spastic cerebral palsy (mean age 36.4 (standard deviation (SD) 5.8) years, 62% male) participated in the study. Approximately 75% had high gross motor functioning. Level of everyday physical activity was measured with an accelerometry-based Activity Monitor and was characterized by: (i) duration of dynamic activities (composite measure, percentage of 24 h); (ii) intensity of activity (motility, in gravitational acceleration (g)); and (iii) number of periods of continuous dynamic activity. Outcomes in adults with cerebral palsy were compared with those for able-bodied age-mates. RESULTS Duration of dynamic activities was 8.1 (SD 3.7) % (116 min per day), and intensity of activity was 0.020 (SD 0.007) g; both outcomes were significantly lower compared with able-bodied age-mates. Of adults with cerebral palsy, 39% had at least one period of continuous dynamic activities lasting longer than 10 min per day. Gross motor functioning was significantly associated with level of everyday physical activity (Rs -0.34 to -0.48; p </= 0.01). CONCLUSION Adults with bilateral spastic cerebral palsy, especially those with low-level gross motor functioning, are at risk for an inactive lifestyle.

A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health

Study design:A prospective cohort study.Objectives:To study the longitudinal relationship between objectively measured everyday physical activity level, and physical fitness and lipid profile in persons with a recent spinal cord injury (SCI).Setting:A rehabilitation centre in the Netherlands and the participants home environment.Methods:Data of 30 persons with a recent SCI were collected at the start of active rehabilitation, 3 months later, at discharge from inpatient rehabilitation, and 1 year after discharge. Physical activity level (duration of dynamic activities as % of 24 h) was measured with an accelerometry-based activity monitor. Regarding physical fitness, peak oxygen uptake (VO2peak) and peak power output (POpeak) were determined with a maximal wheelchair exercise test, and upper extremity muscle strength was measured with a handheld dynamometer. Fasting blood samples were taken to determine the lipid profile.Results:An increase in physical activity level was significantly related to an increase in VO2peak and POpeak, and an increase in physical activity level favourably affected the lipid profile. A nonsignificant relation was found with muscle strength.Conclusion:Everyday physical activity seems to have an important role in the fitness and health of persons with a recent SCI. An increase in physical activity level was associated with an increase in physical fitness and with a lower risk of cardiovascular disease.

Upper limb function in adults with Duchenne muscular dystrophy.

OBJECTIVE To determine upper limb function and associated factors in adults with Duchenne muscular dystrophy. DESIGN Cross-sectional study. SUBJECTS A sample of 70 men with Duchenne muscular dystrophy (age range 20-43 years). METHODS General motor function and, in particular, upper limb distal motor function, were assessed with the Motor Function Measure. Muscle strength and range of motion of the upper limb were evaluated using hand-held dynamo-metry, manual muscle-testing and goniometry. Associations were studied using Spearmans correlation coefficients and multiple linear regression analysis. RESULTS General motor function was severely impaired. Wide variability was found in distal motor function, muscle strength and range of motion of the upper limb, especially in early adulthood. Muscle strength and range of motion explained 76% of the variance in upper limb distal motor function. CONCLUSION This study illustrates a large variability in upper limb function in adult patients with Duchenne muscular dystrophy, and identifies muscle strength and range of motion as factors strongly associated with upper limb function. These results suggest that preserving muscle strength and range of motion in Duchenne patients might be relevant for a better outcome of distal motor function of the upper limb when adult.

Physical fitness in people with a spinal cord injury: the association with complications and duration of rehabilitation

Objective: To assess the association between physical fitness and its recovery over time on the one hand, and complications and duration of phases of rehabilitation on the other. Design and setting: Prospective cohort study at eight rehabilitation centres. Subjects: People with a spinal cord injury were assessed four times: at the start of active rehabilitation (n = 110), three months later (n = 92), at discharge (n = 137) and a year after discharge from inpatient rehabilitation (n = 91). Main measures: Physical fitness was defined as aerobic capacity, determined at each occasion by the peak oxygen uptake (peak Vo2; L/min) and the peak power output (peak PO; W) during a maximal exercise test. On these occasions, spasticity, musculoskeletal and neurogenic pain were determined (1 = present; 0 = absent). During inpatient rehabilitation, complications (urinary tract infection, pulmonary infection or pressure sore) and bed rest were registered (1 = complication; 0 = no complications, and 1 = bed rest; 0 = no bed rest). Complications and bed rest occurring during the year after discharge were registered similarly. Results: Multilevel random coefficient analyses revealed associations in multivariate models (P ≤ 0.05). The peak oxygen uptake was negatively associated with complications after discharge. The recovery of peak power output over time was negatively associated with bed rest and spasticity. Both physical fitness and its recovery were negatively associated with the duration of active rehabilitation. Conclusion: Results suggest that limiting complications, spasticity or bed rest may improve fitness. A longer duration of active rehabilitation is not associated with an increase in physical fitness.

Tetraplegia Hand Activity Questionnaire (THAQ): the development,assessment of arm–hand function-related activities in tetraplegic patients with a spinal cord injury

Study design: Development of Tetraplegia Hand Activity Questionnaire (THAQ).Setting: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium.Objective: To construct a disease-specific questionnaire to evaluate interventions to the arm–hand of tetraplegics in terms of gained and lost activities relevant to the patient.Methods: All arm–hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm–hand as judged by an expert panel, using a Delphi method.Results: The arm–hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the ‘new’ activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%).Conclusion: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm–hand function-related interventions for tetraplegic SCI patients.